Use Of Intracoronary Adrenaline and its Affect on Post PCI Timi Flow
Main Article Content
Abstract
Background: Percutaneous coronary intervention (PCI) has significantly improved the management of acute coronary syndromes (ACS) and chronic coronary artery disease (CAD), reducing morbidity and mortality. The Thrombolysis in Myocardial Infarction (TIMI) flow grades measure the success of PCI in restoring blood flow. However, achieving optimal TIMI flow can be challenging due to complications like the no-reflow phenomenon, which occurs despite successful mechanical opening of the coronary artery and is associated with poor outcomes.
Objective: To assess the impact of intracoronary adrenaline (epinephrine) on post-PCI TIMI flow grades and associated hemodynamic effects in patients experiencing no-reflow or slow-flow phenomena during PCI.
Methods: This retrospective study was conducted at the Interventional Cardiology Department of Hayatabad Medical Complex, Peshawar, from January 1, 2023, to December 31, 2023. A total of 800 consecutive patients who underwent PCI and experienced no-reflow or slow-flow phenomena were included. Intracoronary adrenaline was administered, and data were collected on patient demographics, comorbid conditions, lesion location, TIMI flow grades, and hemodynamic parameters before and after adrenaline administration. Statistical analysis was performed using SPSS software (version 25.0), with paired Student’s t-tests and chi-square tests used for data comparison.
Results: The administration of intracoronary adrenaline resulted in a significant improvement in TIMI flow grades, with complete restoration of TIMI 3 flow in 589 (73.2%) patients. TIMI frame count decreased significantly from 57 ± 11 to 18 ± 09 (p < 0.021). TIMI myocardial blush grade improved from 0.82 ± 0.69 to 2.60 ± 0.63 (p < 0.032). Hemodynamic parameters, including systolic and diastolic blood pressures and heart rate, showed significant improvement post-adrenaline administration (p < 0.001). The incidence of non-sustained ventricular tachycardia was 27%, while sustained ventricular tachycardia was negligible. The need for intra-aortic balloon pump (IABP) and transvenous pacing was documented in 16% of cases.
Conclusion: Intracoronary adrenaline is effective in improving TIMI flow grades and hemodynamic stability in patients with refractory no-reflow following primary PCI for STEMI. The treatment was well tolerated with minimal adverse effects, suggesting its potential utility in clinical practice. However, large-scale randomized studies are needed to confirm these findings and establish guidelines for optimal dosing and administration strategies.
Article Details
![Creative Commons License](http://i.creativecommons.org/l/by/4.0/88x31.png)
This work is licensed under a Creative Commons Attribution 4.0 International License.
References
Tesic MB, Stankovic G, Vukcevic V, Ostojic MC. The Use of Intracoronary Sodium Nitroprusside to Treat No-Reflow After Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction. Herz. 2010;35:114-8.
Hong MK, Mehran R, Dangas G, Mintz GS, Lansky AJ, Pichard AD, et al. Creatine Kinase-MB Enzyme Elevation Following Successful Saphenous Vein Graft Intervention Is Associated With Late Mortality. Circulation. 1999;100:2400-5.
Lee CH, Tse HF. Microvascular Obstruction After Percutaneous Coronary Intervention. Catheter Cardiovasc Interv. 2010;75:369-77.
Eeckhout E, Kern MJ. The Coronary No-Reflow Phenomenon: A Review of Mechanisms and Therapies. Eur Heart J. 2001;22:729-39.
Hashimoto K, Hashimoto K. Cardiac Irregularities Induced by Intracoronary Injection of Epinephrine and Acetylcholine Into Various Portions of the Canine Ventricle. Am Heart J. 1972;83:197-205.
Hoffmann BB, Lefkowitz RJ. Catecholamines, Sympathomimetic Drugs and Adrenergic Receptor Antagonists. In: Molinoff PB, Ruddon RW, editors. Goodman and Gilman’s Pharmacologic Basis of Therapeutics. 9th ed. New York: McGraw-Hill; 1996. p. 199-248.
Goto Y, Maeda T, Goto Y. Effects of Prehospital Epinephrine During Out-Of-Hospital Cardiac Arrest With Initial Non-Shockable Rhythm: An Observational Cohort Study. Crit Care. 2013;17
Skelding KA, Goldstein JA, Mehta L, Pica MC, O'Neill WW. Resolution of Refractory No-Reflow With Intracoronary Epinephrine. Catheter Cardiovasc Interv. 2002;57:305-9.
Gottdiener JS, Bednarz J, Devereux R. American Society of Echocardiography Recommendations for Use of Echocardiography in Clinical Trials. J Am Soc Echocardiogr. 2004;17:1086-119.
Schiller NB, Shah PM, Crawford M. Recommendations for Quantitation of the Left Ventricle by Two-Dimensional Echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr. 1989;2:358-67.
Van’t Hof AW, Liem A, Suryapranata H, Hoorntje JC, De Boer MJ, Zijlstra F. Angiographic Assessment of Myocardial Reperfusion in Patients Treated With Primary Angioplasty for Acute Myocardial Infarction Myocardial Blush Grade. Zwolle Myocardial Infarction Study Group Circulation. 1998;97:2302-6.
Piana RN, Paik GY, Moscucci M, Cohen DJ, Gibson CM, Kugelmass AD, et al. Incidence and Treatment of 'No-Reflow' After Percutaneous Coronary Intervention. Circulation. 1994;89:2514-8.
Rezkalla SH, Kloner RA. Coronary No-Reflow Phenomenon: From the Experimental Laboratory to the Cardiac Catheterization Laboratory. Catheter Cardiovasc Interv. 2008;72:950-7.
Zhou H, He XY, Zhuang SW, Wang J, Lai Y, Qi WG, et al. Clinical and Procedural Predictors of No-Reflow in Patients With Acute Myocardial Infarction After Primary Percutaneous Coronary Intervention. World J Emerg Med. 2014;5:96-102.
de Lemos JA, Antman EM, Gibson CM, McCabe CH, Giugliano RP, Murphy SA, et al. Abciximab Improves Both Epicardial Flow and Myocardial Reperfusion in ST-Elevation Myocardial Infarction. Observations From the TIMI 14 Trial. Circulation. 2000;101:239-43.
Wohrle J, Grebe OC, Nusser T, Al-Khayer E, Schaible S, Kochs M, et al. Reduction of Major Adverse Cardiac Events With Intracoronary Compared With Intravenous Bolus Application of Abciximab in Patients With Acute Myocardial Infarction or Unstable Angina Undergoing Coronary Angioplasty. Circulation. 2003;107:1840-3.
Zeymer U, Zahn R, Schiele R, Jansen W, Girth E, Gitt A, et al. Early Eptifibatide Improves TIMI 3 Patency Before Primary Percutaneous Coronary Intervention for Acute ST Elevation Myocardial Infarction: Results of Randomized Integrilin in Acute Myocardial Infarction (INTAMI) Pilot Trial. Eur Heart J. 2005;26:1971-7.
Saito T, Hokimoto S, Ishibashi F, Noda K, Oshima S. Pulse Infusion Thrombolysis (PIT) for Large Intracoronary Thrombus: Preventive Effect Against the 'No Flow' Phenomenon in Revascularization Therapy for Acute Myocardial Infarction. Jpn Circ J. 2001;65:94-8.
Kloner RA, Forman MB, Gibbons RJ, Ross AM, Alexander RW, Stone GW. Impact of Time to Therapy and Reperfusion Modality on the Efficacy of Adenosine in Acute Myocardial Infarction: The AMISTAD-2 Trial. Eur Heart J. 2006;27:2400-5.
Lima JA, Judd RM, Bazille A, Schulman SP, Atalar E, Zerhouni EA. Regional Heterogeneity of Human Myocardial Infarcts Demonstrated by Contrast-Enhanced MRI: Potential Mechanisms. Circulation. 1995;92:1117-25.
Nijveldt R, Hofman MB, Hirsch A, Beek AM, Umans VA, Algra PR, et al. Assessment of Microvascular Obstruction and Prediction of Short-Term Remodeling After Acute Myocardial Infarction: Cardiac MR Imaging Study. Radiology. 2009;250:363-70.
Pernet K, Ecarnot F, Chopard R, Seronde MF, Plastaras P, Schiele F, et al. Microvascular Obstruction Assessed by 3-Tesla Magnetic Resonance Imaging in Acute Myocardial Infarction Is Correlated With Plasma Troponin I Levels. BMC Cardiovasc Disord. 2014;30:14-57.